[Epidemiology and natural history of primary nonalcoholic fatty liver disease]. / Epidemiología e historia natural de la hepatopatía grasa no alcohólica primaria.

The clinical impact of nonalcoholic fatty liver disease depends on its prevalence and natural history. The prevalence in the adult population is estimated to be about 23% and is on the increase. Thus, it has become the most common cause of persistent elevated liver enzymes, chronic liver disease, and cryptogenic cirrhosis in developed countries. The increasing prevalence of nonalcoholic fatty liver disease, which is approaching epidemic proportions, is parallel to that of other disorders associated with insulin resistance, especially obesity and type 2 diabetes mellitus. This entity occurs in men and women equally and in all age groups. The natural history is poorly defined mainly due to the scarcity of histologic follow-up studies. Although steatosis alone has a more benign clinical course, steatohepatitis is a progressive fibrotic disease, in which cirrhosis and liver-related death occur in a similar way to other causes of chronic liver diseases. Progression seems to be mainly dependent on the severity of histological damage at diagnosis, but age older than 40 years, obesity, and type 2 diabetes have also been associated with an increased risk of liver fibrosis and progression to cirrhosis.

Epidemiología e historia natural de la hepatopatía grasa no alcohólica primaria / Epidemiology and natural history of primary nonalcoholic fatty liver disease

El impacto clínico de la hepatopatía grasa no alcohólica depende de su prevalencia e historia natural. La prevalencia en población adulta se estima en torno al 23% y va en aumento. Así, es ya la causa más frecuente de hipertransaminasemia persistente, de hepatopatía crónica y de cirrosis criptogenética en países desarrollados, y su ascenso, que roza las proporciones epidémicas, es paralelo al de ciertos procesos asociados a la resistencia a la insulina, en especial la obesidad y la diabetes mellitus tipo 2. No tiene predilección de sexo y afecta a todos los grupos de edad. Su historia natural no está definida al ser escasos los estudios histológicos de seguimiento. Aunque la esteatosis simple tiene un curso clínico más benigno, la esteatohepatitis es una hepatopatía fibrótica progresiva en la que la cirrosis y la muerte relacionada con el hígado acontecen de manera similar a otras causas de hepatopatía crónica. La progresividad lesional parece relacionada, en particular, con la intensidad del daño histológico en el momento del diagnóstico, si bien la edad superior a 40 años, la obesidad y la diabetes tipo 2 también se asocian a un riesgo mayor de fibrosis hepática y progresión a cirrosis

The clinical impact of nonalcoholic fatty liver disease depends on its prevalence and natural history. The prevalence in the adult population is estimated to be about 23% and is on the increase. Thus, it has become the most common cause of persistent elevated liver enzymes, chronic liver disease, and cryptogenic cirrhosis in developed countries. The increasing prevalence of nonalcoholic fatty liver disease, which is approaching epidemic proportions, is parallel to that of other disorders associated with insulin resistance, especially obesity and type 2 diabetes mellitus. This entity occurs in men and women equally and in all age groups. The natural history is poorly defined mainly due to the scarcity of histologic follow-up studies. Although steatosis alone has a more benign clinical course, steatohepatitis is a progressive fibrotic disease, in which cirrhosis and liver-related death occur in a similar way to other causes of chronic liver diseases. Progression seems to be mainly dependent on the severity of histological damage at diagnosis, but age older than 40 years, obesity, and type 2 diabetes have also been associated with an increased risk of liver fibrosis and progression to cirrhosis

Caustic sclerosing cholangitis. Report of four cases and a cumulative review of the literature.

We report on four patients of our own and another thirty-six from the literature, who developed almost identical and unusual clinical syndromes after surgical treatment of hydatid disease of the liver, with the aim of showing the extremely serious nature of the problem that can ensue. An association of four factors seems to be necessary to promote caustic sclerosing cholangitis: a) injection of a scolicidal agent (formalin, hypertonic saline, ethanol, silver nitrate or iodine solution) into the cyst cavity; b) a communication between the cyst and the biliary tree; c) a condition that prolongs the exposure of the biliary tree to the scolicidal; and d) a particular sensitivity to the scolicidal agent. While this last condition cannot be anticipated, we may justifiably conclude that surgeons should not inject a scolicidal solution into the hydatid cyst, but prevent intra-abdominal diffusion of the parasite by using hydrogen peroxide, gauze pads moistened by a scolicidal solution or by preoperative chemotherapy with albendazole. Caustic sclerosing cholangitis has an earlier onset of symptoms and a more rapidly progressive nature than primary sclerosing cholangitis. In foresight, serum alkaline phosphatase should be monitored and, when raised, a retrograde endoscopic cholangiogram and/or a liver biopsy should be performed. Digestive shunt surgery should be avoided and the possibility of liver transplantation has to be periodically evaluated.

[Subclinical Crohn disease in acquired immunodeficiency syndrome]. / Enfermedad de Crohn subclínica en el síndrome de inmunodeficiencia adquirida.

We report the case of a patient suffering from acquired immunodeficiency syndrome and hepatitis B and D virus-related cirrhosis of the liver who was diagnosed as subclinical Crohn's disease. We attribute this clinical course to abnormality of intestinal immune system induced by the human immunodeficiency virus. Concomitant hepatitis B and D virus infection may have contributed. This observation supports the hypothesis of helper-inducer T cells (CD4 T cells) having a critical role in the immunopathogenesis of Crohn's disease and its clinical expression.

Rhabdomyolysis and cutaneous necrosis following intravenous vasopressin infusion.

A continuous IV infusion of vasopressin was administrated to a patient with cirrhosis of the liver and acute gastrointestinal bleeding from esophageal varices. In the first 24 hours, the patient developed rhabdomyolysis and cutaneous necrosis. Stopping vasopressin infusion resulted in relief of these lesions. The rarity of these complications suggests an idiosyncratic reaction of susceptible individuals that may be related to previous vascular disease or a failure in baroreceptor regulation.

[Non alcoholic steatohepatitis. Mid-term clinical and histologic course in 10 patients]. / Esteatohepatitis no alcohólica. Evolución clínica e histológica a medio plazo de diez pacientes.

BACKGROUND: The progressive character of the hepatic lesions in nonalcoholic steatohepatitis (NASH) has not been well established. In the present study, the clinical and histological course of this condition was evaluated at medium term. METHODS: Then patients (6 females and 4 males) with NASH, in a non-cirrhotic stage at the time of diagnosis, were followed up during 58 +/- 7 months (range 24 to 88 months). RESULTS: Nine patients were obese, but a significant reduction of body weight was found at the end of the study (p = 0.0072). Other clinical, physical or laboratory changes were not found, although in two cases hepatic biochemical tests were within normal limits when the follow-up biopsy was performed. Changes in the characteristic hepatic features were also absent, although fat infiltrates disappeared in three cases. Six patients had increased fibrosis and a progression of the hepatic architectural distortion; four reached the stage of cirrhosis. The evolution of the hepatic lesion correlated with the interval between diagnostic and follow-up biopsies (r = 0.69; p less than 0.05) and with the reduction in body weight (r = 0.64; p less than 0.05). CONCLUSIONS: In most cases, NASH results in a progressive hepatic distortion with can end in cirrhosis, although the change is slow and silent.

[Muscular necrosis following administration of vasopressin]. / Necrosis muscular tras la administración de vasopresina.

A patient is described who developed liver cirrhosis and variceal bleeding. After a continuous infusion of vasopressin rabdomyolysis occurred. Recovery of the clinical picture and of the muscle enzymes occurred 48 hours after cessation of therapy.

[Diffuse peritoneal mesothelioma. Apropos 2 cases and a review of the literature]. / Mesotelioma peritoneal difuso. A propósito de dos casos y revisión de la literatura.

Two cases of diffuse peritoneal mesothelioma are reported. They were not associated with asbestos exposure and they presented as fever of unknown origin and ascitic syndrome, respectively. The literature is reviewed.

[The prognostic factors and evolution of the quality of life in primary biliary cirrhosis]. / Factores pronósticos y evolución de la calidad de vida en la cirrosis biliar primaria.

The prognostic factors and the evolution of the quality of life were evaluated in 38 patients with primary biliary cirrhosis (94.7% females, mean age 52.6 +/- 2.0 years) followed up for more than 36 months (mean 65.3 +/- 3.7 months). Karnofsky's index significantly declined during follow up (p less than 0.05) in a parallel fashion to modified Child's hepatic functional class (p less than 0.05) and to the days of hospital readmission (p less than 0.05). Eleven patients (28.9%) died, and the median survival was 88.7 months. The comparison of the actuarial curves showed the following to be significant poor prognostic factors at the time of diagnosis: a) clinical: more than one associated autoimmune disease, weight loss of more than 10% of the ideal weight, jaundice, upper gastrointestinal hemorrhage associated with portal hypertension, portal-systemic encephalopathy and a modified Child's hepatic functional class of 9 or more; b) biochemical: serum albumin lower than 3.5 g/dl and bilirubin higher than 2 mg/dl; c) histological: Total histological activity index of 10 or more and erosive necrosis index of 2 or more (Knodell et al.), lobular granulomas, and stage IV (Ludwig et al). A significant correlation was found (p less than 0.001) between the R index of the Mayo Clinic and the mean survival time of our patients. As a temporary policy, we indicate hepatic transplant when R is 9.2 or higher (life expectancy lower than 24 months), awaiting our own probabilistic prognostic model with the inclusion of quality of life criteria.

[Esophageal tuberculosis. Presentation of a case and review of the literature]. / Tuberculosis esofágica. Presentación de un caso y revisión de la literatura.

We describe the case of a 63-year-old woman who had recently developed dysphagia. Oral endoscopy revealed an ulcerated fungating lesion in the middle third of the esophagus. The histologic examination showed granulomas with caseous central necrosis, and the culture in a Lowenstein medium produced M. tuberculosis. There were mediastinic adenopathies, but no other organic involvement with this mycobacterium was demonstrated. We review the other 21 cases reported in the English and Spanish literature over the past ten years.

[Cavitated pneumonia and toxic shock syndrome: presentation of a case]. / Neumonía cavitada y síndrome del shock tóxico: presentación de un caso.

Toxic shock syndrome (TSS) is a potentially fatal acute disease preferentially affecting menstruating women and is related to the use of vaginal tampons seems to be due to an specific exotoxin produced by some Staphylococcus aureus strains. We present here the case of a male patients suffering cavitated pneumonia who developed a systemic clinical picture comparable to TSS. This unusual form of presentation is discussed as well as the diagnostic criteria which define this entity.

[Epidemiology of primary biliary cirrhosis in southern Madrid]. / Epidemiología de la cirrosis biliar primaria en Madrid sur.

This study reports the epidemiologic features of primary biliary cirrhosis in patients admitted to the 12 de Octubre Hospital in Madrid between 1974 and 1988. Among the 54 patients recruited, 45 lived in the hospital surroundings. Ninety-three percent were women with a mean age of 53.7 +/- 15.1 years (range 25 to 76 years). The maximal incidence of the disorder occurred in patients above 60 years. At the time of diagnosis 37.8% were asymptomatic and the mean time to symptoms was 20.1 +/- 18.1 months. The year incidence was maximal in 1982, being the mean year rate of 7.45 +/- 4.9 cases/10(6) inhabitants. This rate was lower in women above 25 years (13.9 +/- 8 cases/10(6) inh/yr). A comparable incidence has been reported in Catalonia and Asturias but it was higher in Navarre. During the study period the prevalence of the illness has increased. By december 1988 the mean incidence for the whole group was 45.5 cases/10(6) inh/yr, whereas it reached 134.1 cases/10(6) ihn/yr in women above 25 years. Environmental, genetic or personal factors contributing to the development of the illness have not been encountered. There was, however, a relationship between the mortality and morbidity rates with the severity of the symptoms and with the degree of histological damage.

[Ménétrier disease. Clinical and histological study of 3 cases]. / Enfermedad de Ménétrier. Estudio clínico e histológico de tres casos.

Three cases of Ménétrier's disease diagnosed and treated in our hospital during the last 15 years are presented. We describe the clinical manifestations as well as the pathological findings; one of the cases was complicated by carcinomatous degeneration. On the basis of our experience, we briefly review the controversial clinical, diagnostic and therapeutic aspects of this rare condition.

[Medical treatment of cholelithiasis. I. Bile acids]. / Tratamiento médico de la colelitiasis. I Parte. Acidos biliares.

Gallstones constitute an important health problem for its prevalence and the cost of its definitive treatment, cholecystectomy. Thus, medical therapy is a necessary and desirable goal. In this study the different means for the non-surgical treatment of gallstones are reviewed. In this first part the pharmacological basis is described as well as the selection of patients. The litholytic mechanism of bile acids, its efficacy and the causes of therapeutic failure are describe.

Plasma arginine vasopressin concentration during laparoscopy.

Plasma arginine vasopressin concentration (pAVP) was determined in 47 patients during the insufflation stage of laparoscopy. Laparoscopy was performed under local anesthesia in 39 patients, and under general anesthesia in 8. Pneumoperitoneum was induced with 3-4 1 nitrous oxide to a maximum intra-abdominal pressure of 10 mm Hg. Induction of pneumoperitoneum resulted in a prompt and significant increase in pAVP in every case. In 34% of cases, pAVP increased two- to fivefold as compared with preinduction levels; in 44.7% of cases, elevations of more than fivefold were seen. Increased arginine vasopressin secretion was not related to underlying liver disease, degree of anxiety, changes in blood pressure, heart rate, pCO2, pO2, serum bicarbonate or plasma osmolality. Elevated pAVP was associated with a significant increase in right atrial pressure. In conclusion, abdominal distension during laparoscopy was accompanied by an increase in pAVP. It seems likely that arginine vasopressin response could be due to a decrease in the left atrial transmural pressure gradient.

[Acute submassive cholestatic hepatitis after treatment with carbimazole. Presentation of a new case and review of the literature]. / Hepatitis colestásica aguda submasiva tras tratamiento con carbimazol. Aportación de un caso y revisión de la literatura.

Carbimazole, an antithyroid agent of the thioimidazole group, can induce unpredictable liver alterations, presumably by hypersensitivity. We describe the case of a hyperthyroid woman who suffered acute submassive cholestatic hepatitis in the course of treatment with this drug. We also review the other seven cases of carbimazole hepatotoxicity previously communicated in the literature.